Can tranexamic acid (TXA) stop a gastrointestinal (GI) bleed?

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) is not recommended for routine use in gastrointestinal (GI) bleeding, particularly high-dose IV TXA, which shows no mortality benefit but increases thromboembolic risks. 1

Evidence-Based Recommendations

High-Dose IV TXA (≥4g/24h)

• Not recommended for GI bleeding 1
• High-certainty evidence shows:
  • No reduction in mortality (RR 0.98,95% CI 0.88-1.09) 1, 2
  • No reduction in rebleeding (RR 0.92,95% CI 0.82-1.04) 1
  • No reduction in need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1
• Increased risks:
  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1, 3
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1, 3
  • Seizures (RR 1.73,95% CI 1.03-2.93) 1, 3

Low-Dose IV/Enteral TXA

• No formal recommendation (insufficient evidence) 1
• Moderate-certainty evidence suggests potential benefits:
  • Reduced rebleeding (RR 0.5,95% CI 0.38-0.88) 1, 3
  • Reduced need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 1, 3
  • Possible reduction in mortality (RR 0.62,95% CI 0.36-1.09) 1
• Limited data on adverse events 1

Upper vs. Lower GI Bleeding

Upper GI Bleeding

• Some older studies suggested TXA might reduce rebleeding and mortality 4
• However, these studies were conducted before modern endoscopic therapy and high-dose acid suppression 1
• Current evidence does not support routine use 1

Lower GI Bleeding

• Recent evidence shows no benefit for TXA in lower GI bleeding 5
• A 2024 randomized controlled trial found no significant effect on blood transfusion requirements 5

Clinical Decision Algorithm

1. For active GI bleeding:

   • Focus on standard care: fluid resuscitation, restrictive transfusion strategy, endoscopic intervention
   • Do not administer high-dose IV TXA (≥4g/24h) 1

2. For patients with ongoing bleeding despite standard measures:

   • Consider low-dose IV/enteral TXA only in clinical trial settings 1
   • Await results of further research on low-dose regimens 1

3. For patients with cardiovascular disease or liver disease:

   • Exercise extra caution with TXA due to increased thromboembolic risk 3
   • Monitor for clinical signs of thrombosis if TXA is used 3

4. For patients with renal impairment:

   • Dose reduction required if TXA is used 3
   • Monitor for neurotoxicity and ocular toxicity 3

Important Caveats

• The British Society of Gastroenterology suggests that use of TXA in acute lower GI bleeding should be confined to clinical trials 1
• The European Society of Intensive Care Medicine explicitly recommends against high-dose IV TXA for GI bleeding 1
• TXA may be more effective when given early (within 3 hours of bleeding onset) based on evidence from other bleeding conditions 3
• Conflicting meta-analyses exist, with some showing benefits 6 and others showing no benefit with potential harm 2
• Most recent and highest quality evidence (HALT-IT trial) showed no benefit but increased adverse events 7, 2

TXA remains a valuable treatment in other bleeding conditions (trauma, postpartum hemorrhage, post-cardiac surgery), but current evidence does not support its routine use for GI bleeding.